Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction:A case report and review of literature

BACKGROUND Mycobacterium tuberculosis(TB)is the causative agent of TB,a chronic granulo-matous illness.This disease is prevalent in low-income countries,posing a significant global health challenge.Gastrointestinal TB is one of the three forms.The disease can mimic other intra-abdominal conditions,leading to delayed diagnosis owing to the absence of specific symptoms.While gastric outlet obs-truction(GOO)remains a frequent complication,its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy.Gastroduodenal TB can cause upper gastrointestinal hemorrhage,obstruction,and malignancy-like tumors.CASE SUMMARY A 23-year-old male presented with recurrent epigastric pain,distension,nausea,vomiting,and weight loss,prompting a referral to a gastroenterologist clinic.Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation.However,treatment was interrupted,possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes.Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall.Resection revealed gastric wall effacement with TB.CONCLUSION Primary gastric TB is rare,frequently leading to GOO.Given its rarity,suspicions should be promptly raised when encountering relevant symptoms,often requiring surgical intervention for diagnosis and treatment.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective:To avoid perioperative complications caused malnutrition,nutrition therapy is necessary in gastric outlet obstruction(GOO)patients.Compared to parenteral nutrition(PN),enteral nutrition(EN)is associated with many advantages.This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.Methods:According to the methods of preoperative nutrition therapy,143 patients were divided into EN group(n=42)and PN group(n=101)between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital.Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage.The generalized additive model and twopiecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.Results:EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO,which is a protective factor,especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy(>3 d)did not accelerate the postoperative recovery of gastrointestinal functions.Conclusions:Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery.For patients with absolute obstruction,no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Gastric partitioning for the treatment of malignant gastric outlet obstruction

BACKGROUND Gastric outlet obstruction(GOO)is one of the main complications in stage IV gastric cancer patients.This condition is usually managed by gastrojejunostomy(GJ).However,gastric partitioning(GP)has been described as an alternative to overcoming possible drawbacks of GJ,such as delayed gastric emptying and tumor bleeding.AIM To compare the outcomes of patients who underwent GP and GJ for malignant GOO.METHODS We retrospectively analyzed 60 patients who underwent palliative gastric bypass for unresectable distal gastric cancer with GOO from 2009 to 2018.Baseline clinicopathological characteristics including age,nutritional status,body mass index,and performance status were evaluated.Obstructive symptoms were graded according to GOO score(GOOS).Surgical outcomes evaluated included duration of the procedure,surgical complications,mortality,and length of hospital stay.Acceptance of oral diet after the procedure,weight gain,and overall survival were the long-term outcomes evaluated.RESULTS GP was performed in 30 patients and conventional GJ in the other 30 patients.The mean follow-up was 9.2 mo.Forty-nine(81.6%)patients died during that period.All variables were similar between groups,with the exception of worse performance status in GP patients.The mean operative time was higher in the GP group(161.2 vs 85.2 min,P<0.001).There were no differences in postoperative complications and surgical mortality between groups.The median overall survival was 7 and 8.4 mo for the GP and GJ groups,respectively(P=0.610).The oral acceptance of soft solids(GOOS 2)and low residue or full diet(GOOS 3)were reached by 28(93.3%)GP patients and 22(75.9%)GJ patients(P=0.080).Multivariate analysis demonstrated that GOOS 2 and GOOS 3 were the main prognostic factors for survival(hazard ratio:8.90,95%confidence interval:3.38-23.43,P<0.001).CONCLUSION GP is a safe and effective procedure to treat GOO.Compared to GJ,it provides similar surgical outcomes with a trend to better solid diet acceptance by patients.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasoundguided gastroentero-anastomosis

Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction(GOO)is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum.GOO can be caused by either benign or malignant etiologies,often resulting in early satiety,nausea,vomiting and poor oral intake.GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies.Traditional treatment options for GOO can be broadly divided into surgical[surgical gastrojejunostomy(GJ)]and endoscopic interventions(dilation and/or placement of luminal self-expanding metal stents).While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting,it has also been associated with a higher rate of adverse events.Furthermore,many patients with advanced metastatic disease are not good surgical candidates.More recently,endoscopic ultrasound(EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches.This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Management of gastric outlet obstruction:Focusing on endoscopic approach

Gastric outlet obstruction(GOO)is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction.The obstructions typically involved in GOO can be benign or malignant.Peptic ulcer disease is the most common cause of benign GOO,and malignant causes include gastric cancer,lymphoma,and gastrointestinal stromal tumor.With the eradication of Helicobacter pylori(H.pylori)and the use of proton pump inhibitors,the predominant causes have changed from benign to malignant diseases.Treatment of GOO depends on the underlying cause:Proton pump inhibitors,H.pylori eradication,endoscopic treatments including balloon dilatation or the placement of self-expandable stents,or surgery.

Gastric Outlet Obstruction by a Hydrocholecyst. A Very Rare Variant of Bouveret Syndrome: A Case Report

It is estimated that between 0.3% - 0.5% of patients with cholelithiasis have biliary ileus, of this small proportion, only between 1% - 3% is complicated by the syndrome described in 1896 by Leon Bouveret. Bouveret syndrome refers to the obstruction of the gastric outlet tract secondary to the passage and impactation of a gallstone in the duodenum, through a cholecystoduodenal fistula. It is most common in women, between the ages of 74 - 77 and is clinically characterized by pain, bloating, incoercible vomiting and anorexia.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer(GC)in the middle-or lower-third regions with gastric outlet obstruction(GOO).Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy.This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy(SPGJ)for obstruction relief,in a patient with GOO.CASE SUMMARY During the initial esophagogastroduodenoscopy,an advanced growth was detected in the lower part of the stomach,which caused an obstruction in the pyloric ring.Following this,a computed tomography(CT)scan revealed the presence of lymph node metastases and tumor invasion in the duodenum,but no evidence of distant metastasis was found.Consequently,we performed a modified SPGJ,a complete laparoscopic SPGJ combined with No.4sb lymph node dissection,for obstruction relief.Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab(programmed death ligand-1 inhibitor)were administered thereafter.A preoperative CT showed partial response;therefore,completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy,and pathological complete remission was achieved.CONCLUSION Laparoscopic SPGJ combined with No.4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer： A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting

Background： Gastrojejunostomy （G J J） and endoscopic stenting （ES） are palliative treatments for gastric outlet obstruction （GO0） caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis. Methods： Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences （WMDs）. Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios （ORs）.Results： Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time （WMD = -80.89 min, 95% confidence interval [CI] = -93.99 to -67.78, P 〈 0.001）, faster resumption of oral intake （WMD = -3.45 days, 95% CI = -5.25 to -1.65, P 〈 0.001）, and shorter duration of hospital stay （WMD = -7.67 days, 95% CI = -11.02 to -4.33, P 〈 0.001）. The rate of minor complications was significantly higher in the GJJ group （OR = 0.13, 95% CI = 0.04-0.40, P 〈 0.001）. However, the rates of major complications （OR = 6.91, 95% CI = 3.90-12.25, P 〈 0.001）, re-obstruction （OR = 7.75, 95% CI = 4.06-14.78, P 〈 0.001）, and reintervention （OR = 6.27, 95% CI = 3.36-11.68, P 〈 0.001） were significantly lower in the GJJ group than that in the E S group. Moreover, GJJ was significantly associated with a longer patency duration （WMD = -167.16 days, 95% CI = -254.01 to -89.31, P 〈 0.001） and overall survival （WMD = -103.20 days, 95% CI = -161.49 to -44.91, P = 0.001）. Conclusions： Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass:A case report

BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously.Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach.Traditionally,this necessitates surgical intervention.Recently,however,the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension,nausea,and melena of two days duration.His imaging illustrated a massively distended stomach.A nasogastric tube did not result in drainage of fluid or decompression of his abdomen.His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended"fluid"-filled gastric remnant.An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant.Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum.The patient underwent emergent angiography with embolization of the gastroduodenal artery.He was discharged with a stable hemoglobin level and resolution of symptoms.Healing superficial gastric ulcers were visualized on a follow-up endoscopy.Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated,and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound directed transgastric intervention.

Bouveret syndrome masquerading as a gastric mass-unmasked with endoscopic luminal laser lithotripsy:A case report

BACKGROUND Bouveret syndrome,also known as gallstone ileus,is a rare form of gastric outlet obstruction accounting for 1%-3%of cases.This condition is most often reported in females.The diagnosis can be challenging and is often missed due to atypical presentations,which occasionally mimic gastric outlet obstruction symptoms such as nausea,vomiting,loss of appetite and hematemesis.The symptoms vary with stone size.Larger stones are managed with a surgical approach,but this carries increased morbidity and mortality.Over the past decade,the endoscopic approach has emerged as an alternative mode of treatment,but it is generally unsuccessful in the management of larger-sized stones.A literature review revealed cases of successful endoscopic treatment requiring multiple sessions for stone sizes measuring up to about 4.5 cm.Here we present a unique case of an elderly patient with Bouveret syndrome with a 5 cm stone mimicking a gastric mass and causing gastric outlet obstruction,who was successfully managed in a single session using a complete endoscopic approach with laser lithotripsy.CASE SUMMARY An 85-year-old female patient presented with 1-month history of intermittent abdominal pain,vomiting,decreased appetite and weight loss.An abdominal computed tomography showed a 4.5 cm×4.7 cm partially calcified mass at the gastric pylorus causing gastric outlet obstruction.Endoscopy showed an ulcerated fistulous opening and a large 5 cm impacted gallstone in the duodenal bulb.Endoscopic nets and baskets were used in an attempt to remove the stone,but this approach was unsuccessful.Given her advanced age,poor physical condition and underlying comorbidities,she was deemed to be high-risk for surgery.Thus,a minimally invasive approach using endoscopic laser lithotripsy was attempted and successfully treated the stone.Post-procedure,the patient experienced complete resolution of her symptoms with no complications and was able to tolerate her diet.She was subsequently discharged home at 48 h,with an uneventful recovery.CONCLUSION In our paper we describe Bouveret syndrome and highlight its management with a novel endoscopic approach of laser lithotripsy in addition to various other endoscopic approaches available to date and its success rates.

Jejunostomy in the palliative treatment of gastric cancer:A clinical prognostic score

BACKGROUND Clinical stage IV gastric cancer(GC)may need palliative procedures in the presence of symptoms such as obstruction.When palliative resection is not possible,jejunostomy is one of the options.However,the limited survival of these patients raises doubts about who benefits from this procedure.AIM To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.METHODS We performed a retrospective analysis of Stage IV GC who underwent jejunostomy.Eleven preoperative clinical variables were selected to define the score categories,with 90-d mortality as the main outcome.After randomization,patients were divided equally into two groups:Development(J1)and validation(J2).The following variables were used:Age,sex,body mass index(BMI),American Society of Anesthesiologists classification(ASA),Charlson Comorbidity index(CCI),hemoglobin levels,albumin levels,neutrophil-lymphocyte ratio(NLR),tumor size,presence of ascites by computed tomography(CT),and the number of disease sites.The score performance metric was determined by the area under the receiver operating characteristic(ROC)curve(AUC)to define low and high-risk groups.RESULTS Of the 363 patients with clinical stage IVCG,80(22%)patients underwent jejunostomy.Patients were predominantly male(62.5%)with a mean age of 62.4 years old.After randomization,the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score.The high NLR had the highest value.The ROC curve derived from these pooled parameters had an AUC of 0.712(95%CI:0.537–0.887,P=0.022)to define risk groups.In the validation cohort,the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756,(95%CI:0.598–0.915,P=0.006).According to the cutoff,in the validation cohort BMI less than 18.5 kg/m2(P<0.001),CCI≥1(P=0.001),ASA III/IV(P=0.002),high NLR(P=0.012),and the presence of ascites on CT exam(P=0.004)were significantly associated with the high-risk group.The risk groups showed a significant association with first-line(P=0.012),second-line chemotherapy(P=0.009),30-d(P=0.013),and 90-d mortality(P<0.001).CONCLUSION The scoring system developed with 11 variables related to patient’s performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Endoscopic ultrasound guided gastroenterostomy:Technical details updates,clinical outcomes,and adverse events

Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has been transformed from an innovative technique,into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction.Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed,giving patients more less invasive options.However,EUS-GE is still a technically challenging procedure.In order to improve EUS-GE,several techniques have been reported to improve the technical details.With EUS-GE widely performed,more data about EUS-GE’s clinical outcomes have been reported.The aim of the current review is to describe technical details updates,clinical outcomes,and adverse events of EUS-GE.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,pruritis,and malaise,a triad that develops secondary to obstruction,which often occurs late in the course of the disease process.The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis,staging,and management of patients with pancreatic cancer.Endoscopic retrograde cholangiopancreatography(ERCP)-guided diagnosis(with brush cytology,serial pancreatic juice aspiration cytologic examination technique,or biliary biopsy)and therapeutic interventions such as pancreatobiliary decompression,intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management.In this review,we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Alternative uses of lumen apposing metal stents

The advent of lumen apposing metal stents(LAMS)has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions.These procedures have garnered popularity due to their minimally invasive nature,higher technical and clinical success rate and lower rate of adverse events.By virtue of their unique design,LAMS provide more efficient drainage,serve as conduit for endoscopic access,are associated with lower rates of leakage and are easy to be removed.Initially used for drainage of pancreatic fluid collections,the use of LAMS has been extended to gallbladder and biliary drainage,treatment of luminal strictures,creation of gastrointestinal fistulae,pancreaticobiliary drainage,improved access for surgically altered anatomy,and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections.As new indications of endosonographic techniques and LAMS continue to evolve,this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

Periampullary carcinoma presenting as duodenojejunal intussusception: a diagnostic and therapeutic dilemma

BACKGROUND:An intussusception is the invagination of one segment of the intestine into another.It is more common in children,but a rare clinical entity in adults, where the condition is almost always caused by tumors. METHODS:A 51-year-old female presented with symptoms of gastric outlet obstruction associated with significant weight loss,but no jaundice.Routine hematological and biochemical investigation,including tumor markers,were normal.Abdominal ultrasound revealed duodenojejunal intussusception,and subsequent CT of the abdomen confirmed it. RESULTS:She underwent a laparotomy,which confirmed duodenojejunal intussusception.On reducing the intussusception and performing a duodenotomy,a periampullary mass was confirmed.Hence,she underwent a pylorus-preserving pancreaticoduodenectomy.Histology confirmed periampullary adenocarcinoma. CONCLUSIONS:Adult intussusceptions are mostly caused by tumors.Contrast CT is the investigation of choice, although ultrasound can be used.One should have a low threshold for suspecting malignancy,obtain frozen section histology,and seek appropriate help at an early stage.

Retrievable puncture anchor traction method for endoscopic ultrasound-guided gastroenterostomy: A porcine study

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)is an alternative method for the surgical treatment of gastric outlet obstruction,but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away.Thus,the technique requires superb skill.In order to improve EUS-GE,we have developed a retrievable puncture anchor traction(RPAT)device for EUSGE to address the issue of bowel tenting.AIM To evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODS Six Bama mini pigs each weighing between 15 and 20 kg underwent the RPATassisted EUS-GE procedure.Care was taken to ensure that the animals experienced minimal pain and discomfort.Two days prior to the procedure the animals were limited to a liquid diet.No oral intake was allowed on the day before the procedure.A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method.Infection in the animals was determined.Four weeks after the procedure,a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia.The pig was euthanized after examination.RESULTS The RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals.All the pigs tolerated a regular diet within hours of the procedure.The animals were monitored for four weeks after the RPATassisted EUS-GE,during which time all of the animals exhibited normal eating behavior and no signs of infection were observed.Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals.No tissue overgrowth or ingrowth was observed in any case.Each animal had a mature fistula,and the stents were removed without significant bleeding.Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSION The RPAT method helps reduce mobility of the bowel.Therefore,the RPATassisted EUS-GE method is a minimally invasive treatment modality.

Stone extraction balloon-guided repeat self-expanding metal stent placement

Self-expanding metal stent (SEMS) placement offers safe and effective palliation in patients with upper gastrointestinal obstruction due to a malignancy. Well described complications of SEMS placement include tumor growth, obstruction, and stent migration. SEMS occlusions are treated by SEMS redeployment, argon plasma coagulation application, balloon dilation, and surgical bypass. At our center, we usually place the second SEMS into the first SEMS if there is complete occlusion by the tumor. We discovered an unusual complication during SEMS redeployment. The guide-wire passed through the mesh of the first SEMS and caused the second SEMS to become entangled with the first SEMS. This led to the distortion and malfunction of the second SEMS, which worsened the gastric outlet obstruction. For lowering the risk of entanglement, we studied stone extraction balloon-guided repeat SEMS placement. This is the first report of a SEMS entangled by the mesh of the first SEMS and stone extraction balloon-guided repeat SEMS placement for lowering the risk of this complication.

A Mysterious Case of a 33-Year-Old Female Schizophrenic Patient Who Ingested a Kilogram of Metals: A Case Report

Introduction: Globally, 20 million people are affected by schizophrenia. In Uganda, the prevalence is reported to be 710 per 100,000 population. Unlike normal adults who are less likely to have foreign body ingestion, patients with mental illnesses such as schizophrenia are at an increased risk of both intentional and accidental foreign body ingestion. Therefore, health workers must be vigilant while assessing such patients not to miss out on the diagnosis as unwitnessed foreign body ingestion presents a diagnostic challenge. Observation: We received a 33-year-old female diagnosed with schizophrenia four years before this admission as a referral. She presented at MNRH A&E with complaints of abdominal pain, non-bilious vomiting, and progressive weight loss. She had multiple admissions in private hospitals before her referral to MNRH where several investigations were done with inconclusive results. Upper GI endoscopy revealed multiple foreign bodies in the stomach. An erect abdominal x-ray was then done to rule out distal gastrointestinal involvement and/or perforation. An emergency laparotomy was performed and over 170 different metallic objects of varying sizes were completely evacuated. She reported that she ingested them in response to the compelling auditory hallucinations but had no intention of self-harm. Conclusion: Foreign body ingestion presents a diagnostic challenge in adults. The various impairments among mentally ill patients put them at an increased risk hence the need for suspicious diagnostic evaluation of those presenting with abdominal symptoms. Both health workers and families have a role to play in the prevention of such life-threatening emergencies.